Pick-Up Request Form
Account Name:
*
Pick-Up Address:
*
Pick-Up Type:
*
Please Select
Specimen Pick-up
Medical Waste Pick-up
Are you SC House Calls or a DMHC Account?
*
Yes
No
Do you have a dropbox?
*
Yes
No
Is the dropbox available after business hours?
*
Yes
No
Earliest Pick-Up Time (ET)
*
Please Select
After 12 PM
After 3 PM
After 5 PM
Sample Type(s)
*
Refrigerated Blood
Covid-19
Ambient Blood
Urine
Frozen Blood
Waste Pick-Up Date:
*
-
Month
-
Day
Year
Location Hours of Operation (ET)
*
File Upload
Browse Files
Drag and drop files here
Choose a file
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Submitters Information:
Full Name:
*
First Name
Last Name
Phone Number:
*
Format: (000) 000-0000.
Email:
*
Title/Position
*
Pick-Up Comment:
Submit
Should be Empty: